Abstract
Injection anthrax was described first in 2000 in a heroin-injecting drug user in Norway. New anthrax cases among heroin consumers were detected in the United Kingdom (52 cases) and Germany (3 cases) in 2009-10. In June 2012, a fatal case occurred in Regensburg, Bavaria. As of December 2012, 13 cases had been reported in this new outbreak from Germany, Denmark, France and the United Kingdom. We analysed isolates from 2009-10 and 2012 as well as from the first injection anthrax case in Norway in 2000 by comparative molecular typing using a high resolution 31 marker multilocus variable-number tandem repeat analysis (MLVA) and a broad single nucleotide polymorphism (SNP) analysis. Our results show that all cases may be traced back to the same outbreak strain. They also indicate the probability of a single source contaminating heroin and that the outbreak could have lasted for at least a decade. However, an additional serological pilot study in two German regions conducted in 2011 failed to discover additional anthrax cases among 288 heroin users.
Highlights
Anthrax infections occur world-wide, but are more frequent in countries with subtropical climate for example in southern Europe, the Balkans, south-eastAsia, South America and Sub-Saharan Africa
Multilocus variable-number tandem repeat analysis (MLVA) for analysis of 31 markers was performed with multiplex polymerase chain reaction (PCR) and capillary electrophoresis as described [25,26]
Dendrogram based on multilocus variable-number tandem repeat analysis (MLVA-31) typing of isolates
Summary
Anthrax infections occur world-wide, but are more frequent in countries with subtropical climate for example in southern Europe, the Balkans, south-east. Primary infections predominantly occur in ungulates, whereas human infections are rather rare and usually associated with contact to infected animals or contaminated animal products, such as meat, fur, bone meal, wool or hair [1,2]. Published laboratory-confirmed anthrax cases in heroin users 2000 to 2012 as of 31 December 2012 (n=69) Number of cases France >5 Denmark Wales
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